SEPTIC TANK INDUSTRY APPLICATION FORM

Includes coverage for:PRODUCTS/COMPLETED OPERATION LIABILITY

COMPREHENSIVE GENERAL LIABILITY

PROFESSIONAL LIABILITY

POLLUTION LIABILITY

INSTRUCTIONS:Please complete the application in its entirety.

Those questions which you deem are not applicable to your company, please insert the initials “N/A”, do not leave blank. If the question is such that a precise answer is either difficult or impossible, then provide a best estimate answer. Should an answer to any of the questions require more space than provided, please provide your answer on a separate sheet of paper, properly identifying the question you are answering. Any other supporting documentation that a question may call for, or you may wish to add, please properly identify the question the documentation is in reference to. The information and representation provided in this application shall form the initial basis upon which an insurance binder may be issued. Accordingly, this application and the material contained therein shall become an integral part of the insurance contract. Material misrepresentations on the application will cause the insurance contract to be void.

1.Corporate or Business Name ______

______

2.Mailing Address ______

______

3. Physical Address ______

______

4.Telephone (______) ______Fax (______) ______

5.Executive for Principal Contact ______Title______

E-mail: ______

6.Company Officer in Charge of Product Liability Insurance ______

7.What legal organization form would describe your company?

 Corporation Partnership  Sole-Proprietorship  Other

If Other please specify ______

8.Website: ______FEIN# ______

9. When does your current Liability Insurance Expire? ______

10. What is the latest date your need your quote? ______

11.How many years has your company been in business? ______

Note: If the business is new, attach a summary of the prior experience of the business owner(s) and key manager(s).

12.How many years has the current management been in place?______

13. Does your company have Branches at other locations?  Yes  No

If yes, please list number ( ____) and addresses of other locations:

______

______

______

(use separate sheet if necessary)

14.What does your company do? Please describe in at least two full sentences.

______

______

______

15. Does your firm do any trenching work that is more than 4 ft. deep? _____ Yes _____ No

  1. If “Yes,” do you use shoring to prevent collapse? _____ Yes _____ No
  2. Are escape ladders provided? _____ Yes _____ No

16. Please provide below your company’s annual receipts:

A. Gross Annual Tank Installation Sales$______

B. Gross Annual Tank Maintenance Sales$______

C. Gross Annual Design or Engineering Sales$______

D. Gross Annual Septic Supplies/Equipment Sales$______

E. Gross Annual Port-a-Potty Rental/Sales$______

F. Other (Describe) ______$______

TOTAL ANNUAL SALES$______

17. Total number of employees? ______

18. What is your annual payroll? $______

19. Do you require Stop Gap Coverage in the following States: Ohio, North Dakota, Washington, Wyoming?

If “Yes,” please list the annual payroll in those states. $______

______

20.Is your company an owner or investor in any other business enterprise in which Product Liability exposure exists?  Yes  No If yes, please briefly describe on a separate sheet of paper.

21.Does your company currently have a specific organized Safety Program?  Yes  No

22. How many field technicians or salespeople do you have? ______

23. What is the total square footage of all owned and rented buildings? ______

24. Are your company premises and equipment inspected or certified by any outside third parties?

 Yes  No

If Yes, please complete the following:

Local Agency Yes  NoName ______

State Agency Yes  NoName ______

Federal Agency Yes  NoName ______

Private Agency Yes  NoName ______

(Use additional sheet if necessary.)

25. Do you dispose of septic tank waste? _____ Yes_____ No

26. If the answer to the above question is “YES”:

A. How many locations do you use for disposal? ______

B.Have you ever been fined or cited for disposal of waste water in an unauthorized place or location?

____ Yes_____ No

C.How many pumper or disposal trucks do you own? ______

27. If you install septic tanks and drainfields, who performs the percolation test?

______

28.Policy Limit Desired:

General Liability, Professional Liability: Our automatic minimum limits of coverage are $1 million per occurrence and $3 million in the aggregate for the primary policy. There is also an automatic pollution limit of $500,000.

Excess Liability $______

Note: Excess Limits over $10 million will require a referral.

Pollution Limit Desired: _Incl. _ $500,000 Occurrence/$500,000 Aggregate

______$500,000 Occurrence/$1,000,000 Aggregate

______$1,000,000 Occurrence/$1,000,000 Aggregate

______$1,000,000 Occurrence/$2,000,000 Aggregate

______$1,000,000 Occurrence/$3,000,000 Aggregate

Note: The policy automatically includes $500,000/$500,000 Limits

Auto Liability Coverage Desired? ____Yes ____ No

Environmental Liability (Additional) Up to $25,000,000 ? ___Yes ___ No: Limit $ ______

29. Name of current Liability insurance carrier(s):

______

Broker Name ______Phone ______

Address ______

30.Liability Claims Experience:

NOTE…..this information is of vital importance, please be as detailed as possible. Begin with any claims that are currently pending and then proceed to any closed claims, listing all the claims in chronological order for the past five (5) years. For ease of providing this information use the Claims Information Sheet attached.

31.Has your company had any liability claims paid by an insurance company in the past 5 years?

 Yes  No

32.Do you or any or your officers, directors or stockholders know of any incident that your company has been involved in that would cause a possible claim or litigation to ensue?  Yes  No

33. Should your application for insurance be approved, please indicate the date you would require said insurance to become effective

Effective Date ______

34. O.S.H.A. CITATIONS, ENVIRONMENTAL AGENCY ACTIONS OR COURT JUDGMENTS

On a separate sheet, or the reverse side of this page, please list only those citations received in the past five (5) years that would relate your Work or Product. Also, please include any notices of Judgment under the Federal Insecticide, Fungicide, and Rodenticide Act.

I HEREBY certify that the aforementioned provided material is true and accurate information as to the best of my knowledge. I further acknowledge that said information and representations will be utilized to determine my company’s insurability and form a basis upon which an insurance policy may be issued.

SIGNED ______

PRINT NAME______

TITLE______DATE ______

35. Please complete the table below:

General Liability Losses
Year / Amount of Loss / Value Date
Last Year
1st Prior
2nd Prior
3rd Prior
4th Prior

PENDING & CLOSED CLAIMS

INFORMATION

Please complete a separate form for each claim you have experienced in the past five (5) years as requested in question #35 of the attached application form. Should you not have available in your files all the information requested, complete what you can and request your broker to provide the remainder. To assist in providing suit information, you may enclose a copy of the lawsuit if you have retained one.

1.Title of Lawsuit ______v ______

plaintiff defendant

______

co-defendants if any

2.Docket or Court Number ______

3.Date of Incident ______Date Suit Filed ______

4.Description of Incident ______

______

______

5.Plaintiff’s Allegations ______

______

______

6.Case is: PENDING  CLOSED 

7.If CLOSED: SETTLEMENT  TRIAL DISMISSED  OTHER 

If OTHER give details ______

______

______

8.If CLOSED, list Date and amount Paid ______

9.Name of Insurance Carrier for this Claim ______

______

10.On a separate sheet list any Citations you may have received and their disposition.

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